Yesterday, a tweet caught my attention from @JasonYoungMD who stated “My Five Foundations of Felling Fine: Food, Fitness, Friends & Family, Falling Asleep, Fulfillment.” This seemed like the best advice I had heard for the newbie interns taking teaching hospitals by storm as well as the rising third year medical students who are about to be unleashed on the wards (if they haven’t already). It also is a great starting point for program directors who are wondering how to ensure that their residents are “Fit for duty” according to the new ACGME rules.

Food – While this is basic part of sustenance, finding food sometimes in the hospital can be challenging, especially at odd hours. Fortunately, this has gotten better, but the choices may not be healthier. In my own hospital, I’ve seen the front lobby transform from a small coffee kiosk (Java Coast which was celebrated when it arrived) to a full fledged Au Bon Pain (ABP as we affectionately refer to it). While ABP was a welcome addition, it is easy to consume a lot of empty calories eating muffins or breakfast sandwiches! To make matters worse, research from one of our very own sleep research gurus has shown that the more sleep deprived you are, the worse food choices you make! Therefore, the thing you will reach for after a night shift is going to be the carbohydrate loaded Danish. Residency programs must know this and usually have morning reports full of this type of food. So, consider how you will make healthy food choices – whether that be bringing your own food, or finding out where the healthy options are. Lastly, don’t forget about the empty calories that come with beverages, especially coffee-related drinks. For you Starbucks fans, there is an app for that – and I guarantee you may change your choices.

Fitness – Like food, fitness can be hard to come by. Interestingly, working in the hospital can actually be a way to get exercise. For example, some studies demonstrate that residents walk as much as 6 miles on call! However, its also just as easy to sit behind a computer and take a “mission control” approach to your call night where you are monitoring all your iPatients. So, think about this and consider wearing a pedometer and most importantly getting into a routine. When time is of the essence, find a way to work fitness into your day like taking the stairs in lieu of the elevator, or parking farther away. If you join a gym, you have to make sure you go…and one easy way of doing this is to make sure your gym is on your way home from work and that is your first stop. During residency, I actually switched to a gym that was directly on my route home that had a parking lot so I literally had no excuse and actually felt guilty while I drove by and did not stop there. Others opted for 24hour gym craze that that could work for anyone’s schedule. Lastly, exercising with a friend will likely lead to greater results than the solo work out.

Friends & Family – Speaking of friends and family, this is the support system that gets interns through residency. Fortunately, another omnipresent F can be helpful here – Facebook. Busy interns or students can at least get reminders to electronically wish your friends happy birthday or log in on that random Monday off to reconnect with friends. It’s also important to set appropriate expectations with your friends and family, for example when you are starting on a time intensive rotation that can be demanding. Because of the intense nature of working in the hospital, some of you will form fast friendships with your co-interns and residents which can be helpful to get you through. However, even your closest friends (including those at work) will ask you to choose between them and sleep- which can be very tough when you are running low on sleep.

Falling asleep –So, speaking of sleep, my first question was where do I sleep? Sounds silly I know, but I actually did not know where the call rooms were or did not have the call room key for my first call night ( I actually can’t remember which) so I ended up going to sleep for an hour in an unoccupied hospital bed. So, this may not be possible today for 2 reasons: (1) interns are not likely sleeping when working the jam packed 16h shifts; and (2) hospital beds are nearly always filled! Still the challenge for today’s interns is getting sleep when working odd hours, especially if starting night shifts on night float or ‘night medicine’ as programs are evolving to include more night rotations. If this means you have to invest in window treatments or wear an eyeshade at night, just do it. There is nothing better than sleep for a resident and the more the better. While your sleep at home may be limited regardless due to your other family obligations, its important to know your limits and set aside nights where you will recover.

Fulfillment – Last but not least, its important to figure out how to keep yourself happy and fulfilled during your residency. In some cases, that is a particular hobby or loved one that you need to stay in touch with. In other cases, fulfillment is more complex. It is not uncommon to have doubts about your future career as you stand by the fax waiting for outside hospital records, wait on the phone to schedule a follow up appointment for a discharged patient, or even transport a sick patient to get a needed test. While many are working on ways to reduce the burden of this largely administrative work, interns and medical students are still straddled with a large amount of scut which can be demoralizing. So, where do you find the fulfillment in your work? Well, you will find it when you least expect it – in the words of a patient who is eternally grateful. In other cases, you will meet a mentor or role model who shares your passion and interest in medicine, whatever that may be, and can inspire you to keep you going. Whatever it is, find it and hang on to it for dear life during your darkest hours and it will pull you through.

I do need to add one more F to this fine list – So provided that you are keeping up with the first 5 F’s, the best thing is that being in the hospital, learning medicine, and caring for patients is actually FUN! So, don’t forget to pause and enjoy it…these tips will also serve you will in the FUTURE!

For the Twitter to Tenure workshop at this year’s Society of General Internal Medicine Meeting, I was asked to think about how social media enhanced my career. This may sound ridiculous at first- after all, social media is a big waste of time right? Wrong as some of you have discovered. Social media has opened doors for me by connecting me to a variety of people I would not have met. Here is just a brief list of the ways social media has impacted my academic career.

Media interviews – I was interviewed by Dr Pauline Chen through the New York Times who located me through – you guessed it Twitter! She actually approached me for the interview by direct messaging me through Twitter. She was following me and noticed my interests in handoffs on my Google profile which is linked to my Twitter account. She was also very encouraging when I started the blog which was exciting!

Workshop presentations- I presented a workshop on social media in medical education (#SMIME as we like to call it), at 2 major medical meetings with 3 others (including @MotherInMed who encouraged me to start a blog and also is my copresenter at SGIM). The idea was borne on Twitter…and the first time I actually met one of the workshop presenters (who I knew on Twitter) was at the workshop.

Acquired new skills – My workshop co-presenter who I only knew through Twitter ended up being Carrie Saarinen, an instructional technologist (a very cool job and every school needs one!). She is an amazing resource and taught me how to do a wiki. After my period of ‘lurking’, I started my own ‘course’ wiki dedicated to helping students do research and scholarly work which we are launching in a week.

Lecture invitations – Several of my lecture invitations come through social media. Most notably, I was invited to speak for an AMSA webinar on handoffs and also speak to the Committee of Interns and Residents on teaching trainees about cost conscious medicine. Both invitations started with a reference to finding me through Twitter or the blog.

Grant opportunities – I recently submitted a grant with an organization that I learned of on Twitter – Initially, I had contacted Neel Shah from Costs of Care asking him if they had a curriculum on healthcare costs. They did not, but were interested in writing a grant to develop a curriculum so they brought my team on board and we submitted together (fingers crossed).

Dissemination - One of the defining features of scholarship (the currency of promotion in academic medical centers) is that it has to be shared. Well, social media is one of the most powerful ways to share information. In a recent example, we entered a social media contest media video contest on the media sharing site Slideshare. Using social media, we were able to obtain the most number of ‘shares’ on Facebook on Twitter which led to the most number of views and ultimately won ‘Best Professional Video.’ To date, this video, has received over 13,000 views, which I was able to highlight as a form of ‘dissemination’ in a recent meeting with our Chairman about medical education scholarship. While digital scholarship is still under investigation with vocal critics and enthusiastic proponents debating the value of digital scholarship in academia, digital scholarship does appear to have a place for spreading nontraditional media that cannot be shared via peer review.

Part of being a good citizen on social media is giving back. I try to give back when I can through helping anyone who contacts me for something specific – so I have read personal statements, reviewed websites, and offered input to others who are interested in my perspective on their work. I can’t always keep up since I have a day job and alas, this is an extracurricular activity. The good news is a tweet is only 140 characters – so like the blue bird, I can keep it short but sweet.

Last month, I was a speaker for AMSA on their patient safety webinar. This was the brainchild of Aliye Runyan, a fourth year medical student at University of Miami and her colleagues, to expand the patient safety taught to medical students. They are not alone. The IHI Open School also virally spreads patient safety training where traditional med schools failed.

My topic was handoffs – and they asked me to talk about it. I wondered what could I tell mostly preclinical medical students, some of whom may not have even entered the clinical arena about handoffs. Would what I say be over their head and irrelevant if they had no clinical context? I was also hoping there were some fourth years on the call who could offer their experience doing handoffs as subinterns.

But, I forgot the importance of fresh eyes, a concept that is sometimes used to describe the one positive aspect of a handoff, that sometimes the best insights come from someone who is not well acquainted with the case. I had a lot of fresh eyes (and mostly ears) on the call. In the vibrant Q&A that followed (and continued via email), one of the things the medical students brought up asked me about something I said is sometimes bad in the signouts- TMI? or Too much information. This often happens when the signout is used to help the primary team track the patient and it loses its function for the receiver. In hospitals with electronic health records, TMI is often a symptom of “CoPaGA” syndrome, or Copy and Paste Gone Amock.

But, this led to the most interesting debate of the night- why has the medical chart become so useless that people feel they need to use the signout this way? I was asked to think about this question again later in a meeting with our Epic staff who are working to create an automatic signout system for our residents – they really wanted to know why we needed a separate system. Since our residents have iPads, why couldn’t they just look at the record?

I had to think about that one. I said that the chart is a document that is an archive that is most helpful for those people that know the patient. It is also one large medical bill. And yes, Dr. Verghese makes excellent points about the iPatient, but the truth of the matter is that the medical record is not all that helpful when you don’t know a patient and you have to make a quick on-the-spot decision. So, this is why we can’t ask busy residents to pause to look in the electronic health record to answer the clinical question of the moment when they don’t know the patient. The information there is overwhelming. Our chief resident had a better answer. The night resident needs the Cliff notes to answer the question since they weren’t assigned (and don’t have time at that moment) to read the full text.

Of course, handoffs are more than just the written information. A handoff also has to include a verbal interactive component. As the implementation of shorter duty hours is looming, so too is a requirement that all residency programs make sure their residents are ‘competent in handoff communications.’ I was asked about this by Dr. Bob Wachter in an interview that was just released on AHRQ Web M&M last week (disclosure – I am on the editorial board). Because programs are looking for a way to meet this requirement, I have racked quite a bit of frequent flyer miles visiting residency programs. But, after I give a talk, I know that they may talk about it for a bit if I’m lucky. Once, I actually witnessed residents putting some of the principles I taught them into action shortly after I spoke at their resident report. However, these moments are isolated and as you can guess, education by itself will not translate into practice change (we could talk to the handwashing people all day about that!). So, like handwashing, a monitoring plan is also needed and yes, that is also part of the new requirement- that programs actively monitor resident handoffs.

This past week was the biggest week in medical education, which culminates in the Residency Match. It also marked the swsx festival in Austin, featuring the best of technology and entertainment. So this post is dedicated to commemorating these two seemingly unrelated yet simultaneous events. The generation that matched are the doctors of the future who are extreme technophiles and not afraid to use it in medicine. They may even make their career decisions based on them. On the interview trail, they will often ask whether the program has an electronic health record. So, as senior students embark into their residency, it seems only fitting to explore how technology is changing medical education. Since there is a lot to say, I’ll write a follow up on how it is affecting preclinical education but the focus is on the match and residency training here.

Technology and the Match During the 2011 residency match, social media was in full force, and the internet was atweeting as medical students, schools, and educators were espousing the #MatchDay and #MatchDay2011 hashtags. Several medical schools actually embraced social media to actively announce where their students were going via Twitter, dedicated blogs, or Flickr (yes Eastern Virgina students wear costumes!). As students celebrated by announcing where they were going, faculty (including myself) could welcome them into their own program. Current interns could rejoice that they were that much closer to the end of their grueling internship, except that they were still going to be on call overnight, while the newly matched have restricted duty hours.

Students often wonder about the size and capability of the mega-computer that runs the algorithm that produces the matches. Unfortunately, this year’s match was marred by a serious computer crash during the precious hours of the Scramble highlighting the worst case scenarios when we depend on technology. The computer crash also does not bode well for the implementation of next year’s Managed Scramble which will increase the numbers of aspiring residents who will use the Electronic Residency Application Service to apply to programs in the post-Match mayhem that is the Scramble. In addition, the current debate over the “All -in” plan will require heavier technological capability as international medical graduates will be required to enter the Match (unlike US Seniors, they can accept positions outside of the Match).

Technology and Residency Training Technology certainly increases our capability in monitoring resident duty hours and collect evalutions through Learning Management Systems like New Innovations or e-Value. However, the implementation of electronic health records actually increases time to do work in many cases, which may make it harder to comply with duty hours. Although decision support can improve quality of care, others worry that overreliance on decision support may result in physicians who subscribe to cookbook medicine and worse, can’t operate without technology. For example, one program director stated that she was going to resort to a ‘blue book’ exam for residents to demonstrate how to do admission orders using the classic mneumonic ADC VAN DISMAL.

More interestingly, just like email and internet has made it possible to conduct business 24/7, the remote access of electronic health records makes it possible to work from home, after you leave the hospital. This may come in the form of ‘epicstalking’ as our attendings and residents refer to it – the process of ‘following a patient’ by looking at the labs and studies through virtually logging in to the hospital’s electronic health record “Epic” from home, long after departing the hospital. Attendings can use epicstalking to ensure that the hospitalized patients are receiving the therapies that are indicated and that the residents are presenting all the information (in essence a form of supervision). However, residents often epicstalk to try to check to see what is going on with the patient they have handed off and gone home, a time when they should be resting. With shorter hours, will more work be transferred home? It is possible, and how this time will be counted in residency duty hours is still anyone’s guess.

In the meantime, maybe a consult to the supersmart Watson can help us tackle these problems?

Also, stay tuned for part 2 which will look at technology and medical student education.

I recently saw a post in Yahoo questions entitled, “Is it illegal for a medical student to introduce themselves as “Doctor” before they have received their MD?” One of the answers that was rated highly was “I think it is more unethical than illegal.”Clearly, if a student is deliberately misrepresenting themselves as a ‘doctor’, it is grounds for disciplinary action. More often than not, this misrepresentation is not deliberate on the part of the student. For example, some of our prior work demonstrates that medical students often report that they were introduced by other physicians as a doctor to a patient and that to a lesser extent, students may not correct someone who mistakes them to be a doctor.

Complicating matters is the propagation of the term “student doctor” at some institutions which is especially problematic. After all, how many patients will be quickly discern that ‘student doctor’ actually refers to ‘medical student’ and not a ‘doctor’? Unfortunately, patients who hear the term ‘student doctor’ may not hear the term ‘student’ and just zero in on the ‘doctor’ part, as they often wait patiently for their doctors to see them in the hospital. This brings us to the problems of how doctors are named in teaching hospitals. The system could not be more confusing.

Interns – This is probably one of the most confusing terms in a teaching hospital. Interns are doctors who have graduated medical school and are in their first year of a residency training program. Of course, ‘intern’ is also the universal term for all those college students trying to get a short term experience on their resume by ‘interning’ there first. So, why would a patient think an intern is a doctor? After all, you would never put your faith in the legal ‘intern’ at the law firm to defend you in a lawsuit. To make matters worse, there is the opposite problem. Intern is often mistaken for ‘internist’, who is actually a doctor who has completed their internal medicine residency and otherwise a ‘doctor for adults.’ (Patients are more familiar with their “PCP” or ‘primary care physician,’ which could refer to either an internist or a family physician).

Residents – Residents can refer to any doctor who has graduated from medical school and is in a residency training program (including interns). The term “residents” originates from William Osler’s era when residents did live in the hospital. Of course, they don’t live there anymore which would violate worker’s rights not to mention their regulated duty hours… but we still call them residents. The other name residents are often referred to is as “PGY1” (post graduate year) which is certainly not an improvement.

Housestaff – One of our premed college students just asked me what this term was this week. I explained that while this does sound like the butler, maid, or cook a fancy estate, this term actually refers to the hospital as the “house” that the residents live in as the staff. So all residents (including interns) are part of the ‘housestaff’.

Fellow – This is perhaps one of the most disconcerting names for a physician as it may sound like it refers only to male doctors (and conjure up images of young man from England with excellent manners i.e. he’s a fine ‘fellow’). In fact, a fellow is a doctor who has completed residency and is getting advanced training in a certain subspecialty.

Attending- Attending to what you may wonder? The attending physician is actually the doctor who has completed training and is legally responsible for the care provided by residents. In other words, this is the ‘boss’ doctor as my residents sometimes introduce me to the patients on our team.

A few years ago, we tried to improve the situation for our patients by having doctors introduce themselves with baseball cards with their pictures on the front and the roles of the doctors were displayed on the back. While we were able to increase the percentage of patients who knew who their doctor was, we were surprised to discover that fewer patients stated they understood the roles of the doctors. How did we make it worse? Perhaps ignorance is bliss. By trying to unlock the secrets of these names, patients realized the names we use in teaching hospitals are confusing.

However, this confusion is more than just a name, it is also a patient safety issue. After 18 year old Lewis Blackman died in a South Carolina teaching hospital without an attending evaluation when his family kept asking to see the doctor, a new law in his honor aims to address the issue. It requires that patients receive written materials describing the roles of the trainees on their team and also how to contact the attending if they have a concern. More recently, the ACGME, which accredits US residency programs, has included a mandate in its now infamous policy restricting resident work hours that states “residents and faculty members should inform patients of their respective roles in each patient’s care.” While it is not certain how this will be implemented at every teaching hospital across the land, it’s certainly time to make our naming system easier and more transparent for patients to understand.

It’s been one year of blogging or our ‘paper’ anniversary here on FutureDocs!

I was reminded of this milestone with the receipt of the WordPress blog ‘report card’ below. While I was excited to learn about the clean bill of health and intrigued by metrics related to shipping containers, I’m not going to lie. It can be very challenging to stay fresh, write creatively, and keep up with posting while holding down an academic career.

However, one thing I have learned (and confirmed by @MotherInMed who helped me get started) was that if you are inspired, the post will write itself (like this one). Therefore, it is critical to pay attention to those moments you are inspired. This gives rise to a somewhat startling personal observation– blogging can acutally improve your attention span and focus. Sounds crazy, I know… But, unlike social media sites which can be highly distracting (Twitter or Facebook addicts anyone?), I find that I often pay closer attention to my surroundings so that I don’t miss the inspirational moment around the corner that I can share. For example, in lieu of walking around aimlessly at medical conferences (a risk at any conference especially in medicine), I found myself taking notes and immediately reflecting on sessions to distill the most salient points, such as the oppressive nature of medical education or expert failure highlighted at the recent Association of American Medical Colleges.

In examining the report card below, the top posts on this blog are both predictable and surprising. With the explosion of interest in technology and plenty of technophiles in the blogosphere, it is no surprise that posts about Twitter myths for docs and whether the iPad lives up to it’s hype on the wards are at the top. The other 2 posts relate to career advising, which was a welcome surprise. They also do reaffirm the need to continue to provide solid career advice to medical trainees, no matter how mundane (like what to wear to the hospital). In addition to technology and career advising, I’ve enjoyed the ability to highlight various advocacy issues relating to medical education like healthcare reform, resident duty hours, the Match, and women in medicine. Lastly, I must admit that I do enjoy writing for pure fun — like the posts on movies in medicine or healthcare phobias.

Special thanks to uber medbloggers KevinMD and medrants who occasionally cross post or reference these posts and all those who subscribe and comment. I was especially honored to be included in KevinMD’s top 10 posts of the year for this post on shadowing (which curiously did not make the WordPress list below).

So here’s to more inspirational and informative moments of 2011, both in life and on the blogosphere.

–Vineet Arora, MD

***Blog Report Card From WordPress:

Fortunately, the stats helper monkeys at WordPress.com mulled over how this blog did in 2010, and sent me the following high level summary of its overall blog health:

The Blog-Health-o-Meter™ reads Wow.

Crunchy numbers

This blog was viewed about 20,000 times in 2010. If each view were a shipping container, your blog would have filled about 4 fully loaded ships.

In 2010, there were 30 new posts, not bad for the first year! The busiest day of the year was March 5th with 304 views. The most popular post that day was Top Twitter Myths & Tips.

Where did they come from?

The top referring sites in 2010 were twitter.com, kevinmd.com, Google Reader, medrants.com, and facebook.com.

It’s the holidays which means that the students are on vacation and faculty have a little more time to unwind. Unfortunately, residents are still hard at work but celebrate the holidays in their own way in the hospital as we have discussed before. I’ll be joining them January 1st but for the moment get to enjoy some time off as well.

Even though medical schools have closed their doors for 2010 and faculty are getting much needed rest, it is time to reflect on what is needed for medical education in the New Year and beyond. While it’s been a banner year for healthcare reform, there are still some issues that are looming large for medical education, especially graduate medical education. It’s important to revisit these issues and especially focus on what the ‘wish list’ as medical education prepares for the ‘twenty-tens’.

Funding to Meet the ACGME 2011 Duty Hour Requirements With 6 months and counting to the implementation of shorter hours for resident physicians, budgets are getting made now for the new fiscal year. On top of that list in teaching hospitals is how to make ends meet with residents who work shorter hours. Residents are low cost labor compared to hospitalists and physician extenders who are their most likely work substitutes. With the overall price tag set at over 1 billion for duty hour compliance, obtaining funding is not easy. However, securing the appropriate financing for these solutions is critical to ensuring that residents are not doing the same or more work in less time. Increasing resident work intensity may undermine any potential improvements in patient safety and resident education. To make matters worse, funding may be harder to obtain than ever since funding for graduate medical education by CMS is under threat of redirection.

A Curriculum to Teach Doctors to Practice Cost Conscious Medicine With an unprecedented focus on how to contain costs and ‘ration’ care, we are missing one key piece of the puzzle – how to teach young physicians and physicians-in-training how to do this effectively. Most faculty physicians do not know the costs of the tests that they order making it necessary to create off-the-shelf curricula in this area. To make matters worse, cost of laboratory tests can vary by region and hospital, making a standard curriculum challenging to implement. Nevertheless, overreliance on medical testing has run rampant in teaching hospitals, largely due to the lamented “demise of the physical exam”. If one way to teach cost-conscious medicine is invest in the low cost physical exam skills, we can all learn from the Stanford 25 that is being resurrected by acclaimed physician author educator Abraham Verghese. While we improve physical exam skills and hopefully change the incentives, we will still need new tools and tips for how to train the cost conscious doctors we wish to produce. One possibility is through the use of narratives – A new group called Costs of Care launched an essay contest to and will be periodically posting stories to help raise awareness.

More Residency Spots – As we’ve discussed, without more spots for all those new medical schools opening their doors, medical school graduates will soon face unprecedented competition during the Match without a corresponding increase in residency positions. While the assumption is that the International Medical Graduates will be squeezed out at the expense of the US graduates, this is not entirely a given. More than a few program directors of IMG exclusive residency programs say they will continue to take International Medical Graduates. Regardless, it’s the US that loses in the end given the projected doctor shortage and the only pathway to licensure is via a US residency. While CMS is exploring ‘redistributing’ spots to primary care, the general consensus is that more will be needed.

Student Debt Relief Medical student debt continues to plague US education. While some programs, such as the National Health Service Corps, have been expanded to help address this issue, it is still important to expand such programs to reach a larger audience of medical students. One novel way to do this is to pair student debt relief with service, an idea put forth by the Editor of Academic Medicine as this year’s “Question of the Year.” Many schools responded, including our own, which created the REACH (Repayment for Education to Alumni in Community Health) Program to help. To achieve a larger scale impact, more programs on a federal and state level are needed. In the interim, the AAMC “FIRST” initiative is a terrific resource to help students navigate their debt and keeps up to date stats about the situation.

Making Primary Care as a Desired Career The shortage of primary care physicians will devastate the US as more patients become insured and the population ages. One of the central models for healthcare reform is the spread of the patient-centered medical home, led by a primary care physician. While the future roles of nursing is explored and potentially expanded to meet this need, it will not be enough to care for complex patients with multiple disease and medications which require care coordination. So, if primary care is so important, why are more students not choosing to go into it? One striking finding in the recently released 2010 survey results of all entering medical students is the number of students who declared they would subspecialize. 12% were already on the “ROAD” (rads, ophtho, anesthesia, derm) while an additional 9% were budding orthopedic surgeons. Meanwhile, 8% were interested in family medicine. Although 18% declared an interest in internal medicine, 2/3 of these will ultimately subspecialize too. So what do entering students already know about these specialties? Well, the elephant in this room here is the income gap between primary care and specialists. As long as this disparity exists coupled with the debt discussed above, it is difficult to dissuade career decisions, especially when they are made this early! No one wants to discuss this since it pits doctor against doctor but the time for this discussion is long overdue.

While it would not be wise to wait up for Santa to deliver on these wishes tonight, keeping our focus on these issues in the New Year will surely help usher in the next decade of medical education.